Brighton Journal of Research in Health Sciences

Supporting Research in the School of Health Sciences


How does exercise affect people who experience extreme states of mind and what impact might this have on mental health nursing practice?


People whose experiences are classified by the medical model as schizophrenia, bipolar affective disorder or psychosis, die 16-25 years sooner on average than people with no mental health diagnosis (Department of Health (DH) 2011b). It is three times more probable they will suffer premature death (DH 2011c), with increased risk of several physical illnesses, such as heart disease, diabetes, respiratory disease and infections, and obesity (DH 2006; DH 2011b,c; Rethink 2013 a, b, c; DH 2014a; NICE 2014b).
The prescribing of anti-psychotic medication may lead to weight gain, sometimes up to 5-6 kg in the first 2 months (Foley and Morley 2011; Rethink 2013a). This may be due to several factors, including a more sedentary lifestyle and a related lack of exercise. The World Health Organisation (WHO 2015) and The Department of Health (2014b) in their policy ‘everybody active every day’ stipulate that adults should be aiming to be active on a daily basis. However 27 million adults in England are not active enough to benefit their health (DH 2012), and the Secretary of State is calling for the NHS to make the promotion of active lifestyles central to all healthcare professionals work (DH 2012).

This literature review topic was chosen because in practice as a student nurse I have thought there is inadequate emphasis placed on exercise and believe that service users would benefit from its inclusion in mental health services.

The phrase ‘extreme states of mind’ (May 2014), is used to describe people in receipt of biomedical diagnoses, such as schizophrenia, bipolar affective disorder, schizoaffective disorder and psychosis. The choice of a non-medical phrase may help in the shift from a medical to a more holistic view of the experiences of people, within which mental health difficulties are described in more compassionate, less stigmatizing ways (Carless and Douglas 2008a; Moncrieff 2009; Johnstone 2014).


In order to first identify the research question, substantial reading was necessary in the field of interest, namely exercise and mental health. A Boolean search was utilised in order to search most efficiently across a range of databases. From this, a few key interests emerged. These were women’s mental health in relation to exercise, the role of the service user voice in exercise, and exercise and serious mental health issues. As there exist a significant number of papers around depression, anxiety and exercise but little on serious mental health issues, my search was made more specific by setting the inclusion and exclusion criteria to only include papers concerning serious mental health issues.
A total of 15 papers emerged as significant. These were predominantly qualitative, with four quantitative and one descriptive study. A simplified thematic analysis was performed on the papers selected (Noblit and Hare 1988; Paterson et al 2001; Rice 2008; Aveyard 2014). Three themes emerged from the papers reviewed, which go some way towards answering the research question: the social, the psychological and the physiological effects of exercise.

Social Effects

The literature signified the importance of the social effects of exercise for people who experience extreme states of mind. The peer support and friendships gained from participation in exercise (Carless and Douglas 2008a, 2008b, 2012; Hodgson et al 2011; Klam et al 2006) appear as a substantial specificeffect, as does the routine and structure it brings to people’s lives (Klam et al 2006; Crone and Guy 2008; Carless and Douglas 2008b; Hodgson et al 2011; Ronngren et al 2014; Cullen and McCann 2015). Participants also identified that exercise positively affects their social roles and highlight the value of shared experience (Crone and Guy 2008; Carless and Douglas 2012; Hodgson et al 2011; Cullen and McCann 2015).

Peer Support and Friendship

Narrative inquiry seeks to find the meaning that people make of their experiences and what it means to be human. It is a creative process that can often bring about change for the participants through the process of re telling the story, narrative re-storying (Carless and Douglas 2008a). The theme of potential benefits through the development of peer support and friendship when exercising was present in several studies. The narrative inquiry work of Carless and Douglas (2008a, 2008b and 2012) hasstrong peer support and friendship themes, and a clear service user voice is heard throughout. These three studies aimed to look at how men experiencing extreme states of mind utilise narrative re-storying through exercise and sport (2008a), how they might receive social support through exercise (2008b) and the narratives of people using physical activity programmes within mental health services (2012). For some people who experience extreme states of mind, the social role that exercise provides is helpful. One participant from Carless and Douglas’s 2012 study typically described his life before engaging in sport as lacking in friends and this meant also he experienced feelings of isolation. This study has a strong service user voice, which makes the pertinence of the statements more compelling. The work of Hodgson et al (2011), supported by Crone and Guy (2008) and Cullen and McCann (2015) also illustrate the role of exercise in alleviating some of the isolation felt by service users through meeting new people in the community.

Psychological Effects

From a psychological perspective, the literature generally revealed how exercise may assist people who experience extreme states of mind to be more motivated, be more proud, confident, have greater self esteem, have fun and alleviate symptoms.


For some, participating in exercise or physical activity led to an increase in motivation to continue exercising (Fogarty and Happell 2005) and in others, exercise increased their desire to make healthy lifestyle changes, such as reducing the intake of fast foods (Klam et al 2006). Motivation can be difficult for people experiencing extreme states of mind, and whether this is because of the impact of medication on motivation or the lack of structure in their lives is unclear (Crone and Guy 2008). In a Norwegian study, Tetlie et al (2009) discussed a mandatory exercise programme in a forensic setting. Mental health professionals participated alongside patients and found this unique approach helped decrease power imbalances on the ward, promoting ‘likeness’. The effects that exercise has on increasing motivation for this population are diverse, although some people are enabled to exercise more (Fogarty and Happell 2005; Warren et al 2011). Nurses exercising with clients may also challenge stigma (Tetlie et al 2009), and this will be explored in more depth in the discussion chapter.


For some, exercise can also be fun and pleasurable, (Klam et al 2006; Crone and Guy 2008; Tetlie et al 2009; Cullen and McCann 2015). Humour in mental health is creatively prioritized by Klam et al (2006), with the incorporation of humour workshops into their ‘personal empowerment program’. In the weeks following this intervention clients were heard sharing jokes and they described how this helped them take life a little less seriously. The fun element was something that was shared between staff and patients in the study by Tetlie et al (2009), further breaking down the barriers between them.


Having fun and experiencing pleasure in life through exercise could also be a way of distracting oneself from the negative experiences of extreme states of mind. It may, according to Cullen and McCann (2015), be a useful tool for voice hearers, as the time spent concentrating on exercise is time spent not concentrating on voices. One participant defined this as ‘it takes you out of living in your mind’ (Cullen and McCann 2015, 61).
Exercise may also counteract boredom, which is often an aspect of inpatient mental health services, and in the community is exacerbated through social isolation (Crone and Guy 2008; Hodgson et al 2011).

Confidence, Pride, Self Esteem, and Sense of Purpose

The effect of exercise on confidence, pride, self esteem and sense of purpose is reported in numerous studies (Crone and Guy 2008; Hodgson et al 2011; Cullen and McCann 2015). Confidence is crucial for participating in social activities (van Deurzen 2012), and self esteem is often interconnected with this (Crone and Guy 2008). In related terms, people who experience extreme states of mind have often lost their confidence (Carless and Douglas 2008a) and sense of purpose (Hodgson et al 2011), and exercise might be something that can help restore this.By extrapolation, the psychological effects of exercise might therefore influence how well an individual participates in society (Tetlie et al 2009) and vice versa (van Deurzen 2012). Peer support, routine and social role positively impact on people’s motivation to exercise, increasing their confidence, pride, self esteem and their ability to have fun.

Physical Affects

The majority of literature included in the review discusses the importance of maintaining good physical health for this population, especially given the negative impact medication and lifestyle can have on diabetes, weight, and the heart (DH 2006, 2011b).


Weight has been identified as a major issue in mental health difficulties (DH 2006; DH 2011c; Mental Health Foundation 2009; NICE 2011; Rethink 2013a, b; NHS 2014b; NICE 2015a). Disappointingly there was only one paper that measured weight loss as a result of exercise (Klam et al 2006). The study by Warren et al (2011) attempted to study weight loss in the USA but was flawed through a lack of accurate data recording, weight gain precipitated by meal vouchers and bias as a result of the involvement of pharmaceutical companies. Other studies have approached the issue but also failed to gain significant results as a consequence of not including diet and nutritional advice in conjunction with exercise (Schwee et al 2013).
Several qualitative studies found that people exercised in order to manage and control their weight. Interestingly, only one study directly found related weight gain and associated issues to the medication prescribed for extreme states of mind – namely second generation antipsychotics (Hodgson et al 2011). Again there are a majority of papers in this review who assert weight gain due to antipsychotic medication in their abstracts, yet only Hodgson et al (2011) reported empirical information on this.

Blood Pressure, Fasting Sugar Levels and Smoking

Klam et al (2006) described positive physical changes to blood pressure, fasting blood sugar levels, smoking and fitness among people with extreme states of mind in Canada. However, this is a descriptive paper and not generalizable. Whilst training for a 5K race, study participants increased their mean steps by 1445.33 over a 10 week period, which is an indicator of increased fitness (Warren et al 2011). Cullen and McCann (2015) highlight that exercise can make someone feel stronger and this motivates them to eat healthier when they can see their physical health improving. It is interesting that physical rather than psychological benefits of exercise were found to be most important to the participants in study by Bassilios et al (2014). This interview-based study of 45 people who use community mental health service around Melbourne, also highlight the importance of education surrounding the benefits of exercise. However, there remains a lack of quantitative evidence in this area. All of this highlights the urgent need to address the physical health of this population. Some studies have approached this issue but have failed to find significant results through poor planning, lack of validity and poor recording (Warren et al 2011; Usher et al 2012; Scheewe et al 2013).



The majority of the studies reviewed recommend that exercise is incorporated into daily mental health practice, which will require support from mental health staff. An important aspect of personal recovery highlighted, is personalised, individualised care. The significance of peer support was a key finding, as was staff exercising with service users.

The literature reflects the importance of exercise staff being highly skilled, especially in mental health. Although personal recovery frameworks advocate increased independence from mental health services, several studies recommended that mental health specific exercise support should be available for those that need it.

It is acknowledged that there are lower participation rates in exercise for women, and also recognised that the stories that women may tell about exercise may be markedly different from men’s accounts. From the literature reviewed, exercise culture can generally be viewed as a male-dominated and thus exercise provision may not be tailored to the needs and requirements of women. Much of exercise provision is based on performance, whereas women might be more interested in the relational outcomes that exercise might bring. This hints at women perhaps gaining more from the benefits of peer support in exercise, but adquate evidence to support this is not currently available.

The positive effects of exercise have been recognised in this review as similar to cohere with the four ontological realms of existentialism, notably the physical, social, spiritual and personal worlds of the individual. The importance of personal meaning and significance is a crucial goal of recovery, and mental health nurses and researchers need to explore this realm with their service users in the context of engagement with exercise.

The findings of the literature reviewed also highlight this, and also point to the benefits of peer support which may also impact on motivation and vice versa. Someone experiencing extreme states of mind might have fun when exercising, which might them lead them to feel more motivated, which in turn may inspire them to do more exercise, thus improving their health, weight and fitness. The literature thus emphasises findings emphasise the interconnected nature of human experiences and how exercise can potentially have an impact on all areas of life.

This review has highlighted the importance of the role of exercise in the process of recovery. This is a subjective process and has a different meaning for each individual, and so, in practice, the personal meaning of recovery emerges as important. Personal recovery models have outcomes differing significantly from clinical recovery, which refers to the reduction and absence of psychiatric symptoms. Personal recovery refers more to regaining social roles, building and consolidating relationships that bring meaning and value to life, and developing hope.

The literature and policy recommend that exercise should be included in mental health services, and specifically to be included in individual care plans. The DH (2012) ‘lets get moving’ pathway has brief interventions already designed, but these need tailoring to this population, which would require more research for it to be evidence based. Clearly, the inclusion of effective exercise in care plans it needs to be supported by mental health professionals.

The DH (2012) state that promotion of active lifestyles is a key role of all healthcare professionals, therefore mental health nurses need to support the promotion of exercise and its sustainment. Nurses also need to be equipped to educate their service users about exercise, know how to refer to other services and instigate practice development where necessary. Crone and Guy (2008) highlight the role of the mental health nurse as practice developers and one emerging suggestion is that they take a role in organising discounts with local sports facilities. For this to be implemented would require nurse education in exercise and a knowledge-base of how to drive practice developments themselves.

If exercise is promoted by mental health professionals and included in care plans it needs to be tailored to individual preferences. Mental health policy and guidelines promote the idea of individual care, especially in personal recovery frameworks. For exercise to be as effective as possible, service users need to be offered a choice of activities and programmes to suit their individual needs. This is especially pertinent for this population, every person’s experiences are unique and require tailored support both generally and specifically in exercise interventions.

The benefits of peer support in exercise, is a potentially interesting finding for future practice development and current guidance is to promote it in mental health services more generally. Peer support in this context is the mutual and reciprocal support provided by another person who has experienced extreme states of mind (Mental Health Foundation 2012). It appears to play a key role as one of the positive effects of exercise. NICE (2014) suggests the use of trained peer supporters in psychosis and schizophrenia and Rethink (2013c) also recommend the use of peers to aid personal recovery.

In practice as a student nurse, I have only met two peer support workers. As a future mental health practitioner I would like to be able to encourage service users to assume this role. It seems clear that they can help contribute directly in the recovery of others and themselves. However, Slade et al (2014) state that this needs to not be tokenistic, ensuring that suitable training and support for this role is in place. For the role of peer support workers to be prioritised in exercise provision, clearly more research is needed.

The review highlighted that in fact exercising with service users was something that increased motivation, reduced stigma and strengthened the therapeutic relationship. Nurses who have undertaken exercise alongside service users have been very positive about its impact, for the services users, themselves and in the case of inpatient services or recovery houses, on the unit as a whole (Happell et al 2012). If this initiative was more widely adopted, nursing staff would be exercising also, therefore taking care of their own physical health needs. However, exercise provision in mental health does demand skilled professionals who are also sensitive to the needs of people experiencing extreme states of mind.

The value of the research into the effects of exercise for people who experience extreme states of mind does not seem sufficient to influence evidence-based practice. Future research is needed in several areas, to include gender sensitivity; how exercise increases meaning in life; peer support, motivation; and service user-led research (Rose et al 2011). Importantly, there is a dearth of significant research included in this review concerning weight loss, which is a key to reducing the health risks that anti-psychotic medication poses. Medication is a contributing health risk of this population, and pharmaceutical companies have an ethical duty to produce medication with less damaging side effects (Bental 2004; Moncreiff 2009).


This review set out to look at the effects of exercise for people who experience extreme states of mind, and how these findings might impact on mental health nursing practice. There is a lack of research in this area, particularly for women, leading to deficiencies in related evidence-based nursing practice. However, the evidence available points to the positive social, psychological and physical effects of exercise.

The literature review recognises that exercise could be used to aid personal recovery, and that this might lead to a less stigmatised view of the individual and their relationship to wider society. The importance of service users being able to re-story their lives through social acceptable activities is highly significant and mental health nursing practice needs to embrace the importance of narrative in all areas of practice. Peer support is already recognised as a vital element of practice and this review recommends that it be explored further in relation to exercise and extreme states of mind. Nurses require education to assist their practice development in these contexts.

Amy Barlow, former Mental Health Nursing BSc(Hons) student


Aveyard, H. 2014. Doing a Literature Review in Health and Social Care. A Practical Guide. 3rd Ed. Maidenhead: Open University Press.

Bassilios, B., F. Judd and P. Pattison. 2014. Why don’t people diagnosed with schizophrenia spectrum disorder (SSDs) get enough exercise? Australian Psychiatry. 22(1): 71-77.

Bentall, R. P. 2004. Madness Explained: Psychosis and Human Nature. Harmondsworth: Penguin

Carless, D. and K. Douglas. 2008a. Narrative, identity and mental health: How men with serious mental illness re-story their lives through sport and exercise. Psychology of Sport and Exercise. 9: 576-594.

Carless, D and K. Douglas. 2008b. Social support for and through exercise and sport in a sample of men with serious mental illness. Issues in Mental Health Nursing. 29: 1179:1199.

Carless, D. and K. Douglas. 2012. The ethos of physical activity delivery in mental health: A narrative study of service user experiences. Issues in Mental Health Nursing. 33: 165-171.

Crone, D. and H. Guy. 2008. ‘I know it is only exercise, but it’s something that keeps me going’: A qualitative approach to understanding mental health service users’ experiences of sports therapy. International Journal of Mental Health Nursing. 17: 197-207.

Cullen C. and E. McCann. 2015. Exploring the role of physical activity for people diagnosed with serious mental illness in Ireland. Journal of Psychiatric and Mental Health Nursing. 22: 58-64.

Department of Health. 2006. Choosing Health: Supporting the Physical Health Needs of People with Severe Mental Illness. Accessed online 17/04/15.

Department of Health. 2011b. No health without Mental Health. Accessed online 11/12/2014.

Department of Health. 2011c. Atypical (Second Generation) Antipsychotics. Accessed online 01/04/15.

Department of Health. 2012. Lets Get Moving. Accessed 10/04/15.

Department of Health. 2014a. Closing the Gap: Priorities for Essential Change in Mental Health. Accessed 04/04/15.

Department of Health. 2014b. Moving More, Living More. Olympic and Paralympic. Games Legacy. Accessed online 20/03/15.

Fogarty, M. and B. Happell. 2005. Exploring the benefits of an exercise program for people with schizophrenia: A qualitative study. Issues in Mental Health Nursing. 26: 341-351.

Foley, D. and K. Morley. 2011. Systematic Review of Early Cardiometabolic Outcomes of the First Treated Episode of Psychosis. Archives of General Psychiatry. 68(6): 609- 616.

Happell, B., D. Scott, C. Platania-Phung and J. Nankivell. 2012. Nurses views on physical activity for people with serious mental illness. Mental Health and Physical Activity. 5: 4-12.

Hodgson, M., H. McCulloch, and K. Fox. 2011. The experiences of people with severe and enduring mental illness engaging in a physical activity programme integrated into the mental health service. Mental Health and Physical Activity. 4: 23-29.

Johnstone, L. 2014. A Straight Talking Guide to Psychiatric Diagnosis. Ross-on-Wye: PCCS Books.

Klam, J., M. McLay, and D. Grabke. 2006. Personal empowerment program: Addressing health concerns in people with schizophrenia. Journal of Psychosocial Nursing. 4(8): 20-28.

May, R. 2014. Blog. Accessed 11/12/2014.

Mental Health Foundation. 2009. Moving on Up. Accessed online 20/02/15.

Mental Health Foundation. 2012. Need2Know Briefing: Peer Support. Accessed 22/04/15.

Moncrieff, J. 2009. A Straight Talking Guide to Psychiatric Drugs. Ross-on Wye: PCCS Books.

National Health Service. 2014b. Valuing mental health equally with physical health or “Parity of Esteem”. Accessed online 11/04/15.
NICE. 2011. Preventing type 2 diabetes: population and community-level interventions. Accessed online 25/03/15.

NICE. 2014b. Psychosis and schizophrenia in adults: treatment and management. Accessed online 23/03/15.

NICE. 2015a. Psychosis and schizophrenia in adults. Quality statement 7: Promoting healthy eating, physical activity and smoking cessation. Accessed online 20/03/15.

Noblit, G. W. and R. D. Hare. 1988. Meta Ethnography: Synthesizing Qualitative Studies. Qualitative Research Methods Series. (11). London: Sage.

Paterson, B, S. Thorne, C. Canam, and C. Jillings. 2001. Metastudy of Qualitative Health Research. Thousand Oaks, CA: Sage Publications Inc.

Rethink. 2013a. The abandoned Illness: A report by the Schizophrenia Commission. Accessed online 10/04/14.

Rethink. 2013b. Lethal Discrimination. Accessed online 25/03/15

Rethink. 2013c. 100 ways to support recovery. Accessed online 07/04/15.

Rice, M. J. 2008. Evidence-based practice in psychiatric and mental health nursing: qualitative meta-synthesis. Journal of the American Psychiatric Nurses Association .14 (5): 382-5.

Ronngren, Y. M., A. Bjork, D. Haage and L. Kristuansen. 2014. LIFEHOPE:EU: Lifestyle and healthy outcome in physical education . Development of a lifestyle intervention program for people with severe mental illness. Journal of Psychiatric and Mental Health Nursing. 2: 924-930.

Rose, D., J. Evans, A. Sweeney, and T. Wykes. 2011. A model for developing outcome measures from the perspectives of mental health service users. International Review of Psychiatry. 23(1): 41–46.

Slade, M., M. Amering, M. Farkas, B. Hamilton, M. O’Hagan, G. Panther, R. Perkins, G. Shepherd, S. Tse, and R. Whitely. 2014. Uses and abuses of recovery: Implementing recovery-orientated practices in mental health systems. World Psychiatry. 13: 12-20.

Schwee, T. W., F. J. Backx, T. Takken et al. 2013. Exercise therapy improves mental and physical health in schizophrenia: A randomized controlled trial. Acta Psychiatric Scandinavia. 127: 464-473.

Tetlie, T., M. C. Heimesnes, and R. Almvik. 2009. Using exercise to treat patients with severe mental illness. Journal of Psychosocial Nursing. 47(2): 30-40.

Usher, K., T. Park, K. Foster and P. Buettner. 2012. A randomised control trial undertaken to test a nurse-led weight management and exercise intervention designed for people with serious mental illness who take second generation anti-psychotics. Journal of Advanced Nursing. 69 (7): 1539-1548.

van Deurzen, E. V. 2012. Existential Counselling and Psychotherapy in Practice. 3rd Ed. London: Sage.

van Deurzen-Smith, E. V. 1984. Existential therapy. In: Individual Therapy in Britain, edited by W. Dryden. London: Harper and Row.

Warren, K. R., P. Ball, S. Fieldman, F. Liu, R. P. McMahon, D. L. Kelly. 2011. Exercise program adherence using a 5 kilometer (5K) event as an achievable goal for people with schizophrenia. Biological Research for Nursing. 13(4): 383-390.

World Health Organisation. 2015. Physical Activity. Accessed online 03/03/15.


Promoting young people’s resilience through enjoyable structured activities.


Concerns about child protection and wellbeing have been increasing in the UK (Kids Company 2014) and internationally (WHO 2012), particularly for those experiencing significant adversity. Such adversity has been defined as intense and/or persistent negative life events including: neglect, abuse, poverty, mental health challenges, addictions, disability and discrimination (Hart et al 2007). Lack of appropriate supports to respond to adversity can have a detrimental impact on children’s development and adult life (Masten and Cicchetti 2010). Resilience involves a dynamic process of positive adaptation to adversity and, accordingly, a resilience frame of reference can facilitate the understanding of young peoples’ strengths and challenges (Hart et al 2007, Masten 2011). Assessing resilience requires taking into account assets and resources within an individual and their environment, and longitudinal processes that lead to resilient outcomes (Ungar 2009). Successful recovery from adversities can contribute to future resilience and debate has focused on internal factors and external factors that may promote resilience (Rutter 2012); yet an occupational perspective (Wilcock and Hocking 2014) calls attention to the potential role of human doing which involves an interaction of internal capacity with the external world.

Literature review

Current resilience research employs multidisciplinary approaches to investigate how individual and environmental factors work together to promote resilience among the most disadvantaged youth (Hart et al 2007, Masten 2011). This includes expanding the evidence base for activity-based interventions (Hart and Heaver 2013) and exploring the perspectives of the professionals involved (Teram and Ungar 2009). A resilience research project, Imagine (2015), has proposed investigating past resilience-building strategies to facilitate reflection on current practices and enhance service provision.

Some studies suggest that activity participation can enhance resilience in young people through development of positive self-identity, including improvement in self-esteem, sense of control, self-awareness, coping, taking care of themselves, confidence, belonging, satisfaction, goal-orientated behaviour and optimism (DeLuca et al 2010, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). Accordingly, Jessup et al (2010) and Grunstein and Nutbeam’s (2007) found leisure activities promoted all of the above.

Participation in leisure activities and apprenticeships has been linked to the resilience indicators of improved learning outcomes, and development of new roles and responsibilities (Hart et al 2007, Ungar 2009). A robust study (Scholl et al 2004) found that graduates with and without disabilities from a youth apprenticeship programme reported advancement in their technical, communication, problem-solving and time-management skills, and made meaningful work transitions with appropriate support. Other studies identified a positive impact of leisure or vocational activities on school performance and further education (DeLuca et al 2010, Hart and Heaver 2013, Jessup et al 2010, Woodier 2011).

Developing friendships, interpersonal skills and belonging to supportive relationships is another resilience domain (Hart et al 2007, Masten 2011) associated with activity participation (Grunstein and Nutbeam 2007, Hart and Heaver 2013, Scholl et al 2004, Woodier 2011). DeLuca et al (2010) illustrates the important role of support and guidance in facilitating these positive outcomes. Two case studies were compared and demonstrated that appropriately graded adult assistance during an apprenticeship promoted positive personal, inter-personal and work outcomes. Conversely, lack of support was found to result in gradual disengagement until help was provided.

These findings are consistent with Wilcock and Hocking’s (2014) theory that through doing people shape who they are – they become – particularly as they move into adulthood. Thus receiving professional support and belonging to a social group appears to be important in promoting occupational wellbeing and resilience. Participation in appropriately structured play/leisure, exercise and employment related activities may address occupational injustice and the resilience indicator of meeting basic needs (Hart et al 2007, Masten 2011, Ungar 2009).

Evidence suggests that activity participation can promote resilience, however, the studies reviewed have a number of methodological limitations, including the lack of detailed description of settings, participants and interventions. Only Jessup et al’s (2010) research focused on leisure activities and only one study (Woodier 2011) was UK-based. Of the studies which included practitioners’ perspectives (DeLuca et al 2010, Woodier 2011) – just DeLuca et al (2010) provided in depth description of specific practitioner support strategies used to promote resilience.

Some longitudinal studies ranging up to three years were identified, but no papers presented accounts of past practices. Historical research may help to capture the complex processes of adversity and the use of occupational strategies in adapting to life transitions, including the change in availability of adequate supports (Kirk and Wall 2010, Wiseman and Whiteford 2007). Research into past practices may illuminate changes in both individual and organisational resilience over time. The research reported below explored the role activities have played in service provision over recent decades and its impact on youth resilience.

Reviewing the current literature led to the formulation of the following research question: how did retired professionals use activities to promote the resilience of young people they previously supported?


Study design

Ethical approval for this study was granted by the relevant University Research Ethics Panel. A qualitative approach was chosen for this exploratory study (Silverman 2010) underpinned by a critical realist ontological and epistemological position (Danermark et al 2002). This methodology holds that while every vulnerable youth experiences their situation of adversity subjectively, the reality of the adverse circumstances exists independently of that experience. Therefore it is valid for critical realist research to try and identify explanations for phenomena which may be relevant to different individuals in related contexts. The impact of the researcher’s experiences and views was acknowledged in line with a critical realist perspective that interpretations of reality will vary according to the perceptions and attributes of different people (Archer 1995). In-depth interviews were conducted with retired professionals to gain accounts on how they had previously used activities to promote young people’s resilience.


Purposive (snowball and criterion) sampling was used to recruit five participants allowing gathering of rich information within limited time constrains (Silverman 2010). The participants were retired people aged over 60 who had worked in health, social care and education and who used activity-based strategies to promote resilience in young people (aged 12-18) experiencing adversity in the UK. Participants were able to give their consent, had fluent English and confirmed that the young people they discussed were over 18 at the time of the research interview. The first five respondents were interviewed.


After consent was gained, approximately 80 minutes long interviews were carried out on university premises using semi-structured open questions, examples of which participants were given in advance. The questions included ‘Could you describe how you used an activity with a young person you worked with?’, ‘Could you describe the types of adverse situations the young person was going through?’ and ‘How did the activity engagement make a difference in the life of…?’ These questions were informed by resilience literature (Masten 2011, Ungar 2009) and discussions with boingboing resilience forum members (boingboing 2013), and their utility was confirmed by a pilot interview. During the interviews further prompts were given to encourage participants to expand or clarify particular points. These interviews were audio-taped and transcribed using pseudonyms to ensure confidentiality.

Data analysis

Data were analysed using a two stage narrative analysis methodology as rich narrative accounts can help to understand the meaning and social significance of the activities in a particular context (Polkinghorne 2010). The first stage was the creation of a chronologically organised core story with a beginning, a middle, an end and contextual factors (Clandinin and Connelly 2000). This chronological picture of the events afforded the potential to suggest the difference the activity participation made (Polkinghorne 2010). The second stage was interpretative and involved looking for regularly reoccurring themes within individual narratives and across them (Clandinin and Connelly 2000). Some themes emerged from the data and some were informed by the authors’ existing understanding of wider literature thus a combination of inductive and deductive approaches were used consistent with the critical realist methodology (Danermark et al 2002).

Credibility was enhanced through member checking in which participants were invited to comment on the key themes (Silverman 2010). The researcher also used a reflective journal throughout the duration of the research to ensure the confirmability.


The five participants came from social work, family therapy and teaching professions. Their detailed narratives covered periods of up to thirty years from the present. 12-18 years old youths’ experiences of adversity were found to be related to bereavement, trauma, anger management, anxiety, poverty, social deprivation, domestic violence and disabilities. The background characteristics of participants are described in table 1 below and a summary of their reported activity-based interventions for young people are shown in table 2. (Names of all individuals and organisations have been changed to protect anonymity).

Table 1. Participant practice information

Participants reflected on the most recent 10 years before they retired.

  • Matt – began career as youth worker in 1970s subsequently qualified as a social worker and then as a family therapist. Retired in 2012.
  • Jude worked as Special Educational Needs Co-ordinator in schools and nurseries since 1980s. Alongside that she volunteered at the Sparkle – a charitable organisation that provided weekly activities and occasional trips. Retired in 2013.
  • Sam – social worker at the Rainbow – a country-side based residential place offering ‘youth in trouble’ support to engage in constructive activities over the weekends. Retired 30 years ago.
  • Pat – qualified as social worker in 1980s. Discussed experiences at The Sunshine – a centre supporting children with learning and physical disabilities. Retired in 2012.
  • Ruth qualified as a primary school teacher in 1970s. Also volunteered with various youth organisations. Retired in 1990s.

Table 2. Summary of young people’s background, interventions and outcomes.

The adversities faced by young people:

  • Antisocial behaviours: stealing, lying, aggression, violence, property damage, youth offending.
  • Poor school performance/attendance/suspended.
  • Childhood trauma, including parent’s death, divorce, illness, single parenting, drinking, unemployment, chaotic routines, abuse, domestic violence, ‘bad parenting’.
  • Physical, mental health and learning difficulties/disabilities, substance misuse.
  • Poverty and financial struggles.

Activities used:

Mindfulness, family therapy, liaising with school and parents, (international) camping trips, running hip-hop groups, cooking, making beds, looking after chickens, Qi Gong, games, roller-skating, football, ice-skating, canoeing, walking in the woods, gardening, painting, knitting, visiting theatre, volunteering, psycho-education.


– representing mechanisms and contextual factors associated with participation in structured activities which influenced young people’s resilience – were identified from the data. These were: promoting positive emotional experience and expression; developing routines, responsibility and roles; constructive relationships; and, social policy and service-level change. These themes are presented in further detail below.

Promoting positive emotional experience and expression

Most participants stated that activity engagement promoted positive emotions in youth. Special Educational Needs Co-ordinator (SENCO) Jude explained that the games they play should always be fun. “That’s the whole essence of it in my mind. If they’re fun, then the children enjoy playing them.” While most enjoyed exploring a variety of activities, gardening was the only occupation that Eva took pleasure in and benefited from. “Everybody else was at the same stage as she was. She felt more at ease, […] less tense, more amenable and interested in what would happen – to see the flowers come out, the tomatoes forming”, reflected primary school teacher Ruth.

Activity enjoyment was also linked to increased confidence and self-esteem. For example, Bob was bullied at school and was never picked to play football, one of his favourite sports, as “macho boys would pick big guys” to join their team. The staff arranged for him to beselected, and “he was good at it – very quick and agile. […] The next time the other team wanted him as well”, remembered social worker Sam. This helped to build his self-respect, confidence and maturity – “he would not accept being bullied anymore”. This shows that increased resilience can enhance youth’s ability to both cope with and challenge adversity.

Family therapist Matt considered that embodied meditative activities transformed negative energy into positive and aided emotional and physical healing. “Sara could write a book on anxiety management. But in her body she was still experiencing huge anxiety’, recalled Matt. She stopped going to school and spent her days in bed. Qi Gong helped her to use negative anxious energy in her body, gather warm calm positive energy, placing and storing it in her lower belly. A few months later Sara returned to school and was relatively free from Irritable Bowell Syndrome.

Similarly, mindfulness-based approaches helped Paul to develop awareness and management of his anger enabling him to be happier and work towards his aspirations. Mindfulness helped Paul to notice the physical sensations in his hands, and how this related to his thoughts and feelings. “If you notice your hands clenching, is that happening when you are relaxed, tense, feeling angry? If the hands are relaxed, then you are relaxed”, explained Matt. Paul had to physically release his hands when they were tensing up. “With kids, if you get them to work with their bodies, it’s much easier than getting them to work with their emotions.” Paul did not get involved in any further violence. He returned to college and did well, aspiring to enter the same skilled trade as his father. Such enjoyable and meditative activities helped promote healing, active engagement, positive self-image and confidence.

Developing routines, responsibility and roles.

Improvement in structured routines, learning, sense of responsibility and future transitions was another category of reported resilience outcomes. Some young people had difficulties with following structured routines due to “chaotic” home environments, explained social worker Sam. A countryside-based residential home ‘Rainbow’ provided them with such opportunities for up to three days a week. They had to get up at certain time in the morning, help to make beds and prepare meals (some discovered they liked vegetables).

On occasions occupational participation involved disappointments and subsequent feelings of guilt, which, when reflected upon, could foster a better understanding of the consequences of their actions and a stronger sense of responsibility. Sam explained, “The big boys would go out and make sure the fox does not get any chickens. One day the fox got some of the chickens and they were very sad about that. Next time they would make sure the fox would never get any chickens.”

Improvement in anti-social behaviours could arise from being encouraged to take responsibility. Jude described how one boy “was at his best [and enjoyed himself] when I said ‘Will you push the wheelchair?’ […] Other times, I remember at one camp where he was on the top of that dung heap swearing loudly as people were passing. Give him a bit of responsibility, and […] he could rise to the occasion and do well and be successful.”

All the professionals wondered if the resilience that the activity promoted at the time had supported future transitions. There was evidence of improved school attendance and performance as Sara’s and Paul’s stories demonstrated, and they subsequently expressed clear aspirations for the future. Primary school teacher Ruth reflected that development of interests and skills could influence career choices. “It was amazing how some children would learn to cook, get a badge and eventually become a chef.” . Sometimes small improvements were observed while other times professionals were uncertain as to whether resilience was carried into home and school environments.

For some resilience only really manifested itself in adulthood. For example, Nora presented with difficult behaviours at the youth organisation. “But her lowest time was when she wasn’t [there]. She was virtually living on the streets for a while. […] She turned up to help years later. Her mother […] was incredibly impressed with her. […] Maybe all those experiences have given her real empathy. She really has turned a corner and is a very pleasant young woman […] training to be a social worker”, stated Jude.

Constructive relationships

According to the participants, structured activities could promote collaboration, constructive role-modelling, strong friendships, autonomy and reduction in antisocial behaviours. Teamwork was considered important by Jude because, “we all do our best if we cooperate rather than be in competition.” Cooperation was promoted by encouraging youth to play without winners and losers, learning to negotiate and compromise. “If you have never had socialisation and responsibility to a group you won’t [compromise] because the child is so strong in you”, explained social worker Sam.

Many professionals reported young people learned to consider and help others through engagement in structured activities. 14 year old Ann spent “so much time thinking about her own problems, things that she didn’t like […]”, remembered Jude. When they went on a camping trip overseas “everybody was ill [and] I expected her to be one of the worst, but […] she actually rose to the occasion.” She helped the children “who were really rough. […] Seeing somebody in a worse situation helped her to see that she had to think about them. […] I saw a side to her that I hadn’t seen anywhere else.”

Sometimes helping others involved becoming a role model of how to behave, being caring and helpful. “The younger ones knew they could rely on this older girl who was there to help to look after them’, recalled school teacher Ruth. Social worker Sam reflected that supporting others allowed children to learn that everybody has different strengths. She recounted how a 12 year old boy was teaching her roller-skating. “I was petrified – ‘I’m going to fall, break my neck!’ And he would say, ‘you won’t fall’. There was roundness in the relationship – it was not just about us teaching them.”

A few participants emphasised that activities helped to establish strong friendships that continued years after they left the youth organisations. Jude remembered Simon had “a massive head injury” as a result of a serious car accident. When his friends from the Sparkle went to see him, “he realised who they were and went to speak to them. His father was almost in tears because it was the first indication that his mind was working properly.” Simon made “a remarkable recovery” and his friends from the Sparkle “have been supporting him during all this time.”

Therapeutic support

Most professionals acknowledged that they played a central role in ensuring the activities were enjoyable and successful. SENCO Jude’s experience suggests that the role of the facilitator is to ensure that activities are fun. “It’s got to remain fun. If it doesn’t, then you quickly adapt the rules or move on to a different game. You don’t want to knock their confidence. You need to be vigilant.”

Professionals reported they nurtured youth’s resilience through role-modelling, encouragement, feedback and guidance within a safe space. Jude knew Peter was able to dance hip-hop, and so consistently encouraged and supported him to run a session for the younger ones. “I think he felt very pleased with himself afterwards.” With Jude’s guidance Peter was able to encourage a boy with learning difficulties who already knew some hip-hop. “It’s the sort of double-edged success. It’s a lot to do with giving opportunities, but then support to make sure that it does work.” By contrast, according to family therapist Matt and social worker Sam, some unstructured activities with peers could promote antisocial behaviours and maladaptive coping strategies.

Helping young people to reflect on their experience was an important part of the process. Family therapist Matt enabled Paul and his family to share their experience of bereavement exploring helpful strategies in supporting each other. While Eva was supported to explore “the other person’s point of view”, according to primary school teacher Ruth.

Social Policy and Service-level change

Some participants reflected that the integration of services, including working with families as a whole can help to sustain resilience outcomes, and considered they had witnessed improvements in this over time. According to social worker Sam who retired 30 years ago “there weren’t enough communication and togetherness [between the organisation and the parents]. It was quite isolated – we took them out of that sphere and put them in another. Our job was limited to 48 hours”. However, in more recent social worker Pat’s experience, “you are supporting the family so the family can keep the child at the centre. […] Now family social workers, might suggest working with brother and sister together […]. In those days there was nothing like that.”

Continuity of funding of youth organisations was reported to be a significant challenge in both the recent and more distant past. It led to the closure of the Rainbow thirty years ago and elsewhere it was implied that limiting therapy input might have contributed to Sara’s and Luke’s relapses. Matt and Jude reflected that getting government grants, is much more difficult now, and that time-limited interventions, targets and long waiting lists have become more predominant. Matt stated that in mental health services more funding is being directed towards talking therapies, while forty-fifty years ago “activities were all we ever did”. By contrast, social worker Sam believed activity participation has become more valued in school settings.

Some participants considered the sort of resilience-building work they used to do is being challenged by increasing recording on complex computerised systems as part of a drive to evidence accountability. Pat was concerned this can reduce the direct contact of working with children and their families. Sam was apprehensive about the lack of flexibility, increased focus on materialism and negative perceptions regarding being tactile with children. She was among those who expressed a relief they are not part of the current system.


A range of different activity types were reported, often closely aligning meditative or cognitive approaches, and those based more on activity itself. Retired professionals’ descriptions of the impact activity participation had on young people facing a range of adversities revealed commonalities. Structured activities promoted competence, confidence, self-esteem, self-awareness, roles, routines, responsibility and constructive relationships as was also found by Hart et al (2007), Jessup et al (2010) and Scholl et al (2004). Sometimes this translated into long-lasting friendships, better learning outcomes and future achievements supporting the findings of DeLuca et al (2010) and Woodier (2011).

The extent to which resilience was achieved varied and appears to have depended on a number of factors. Successful outcomes were linked to positive emotional experience. This elaborates upon some findings in previous studies that have made more limited reference to role of positive emotions in building resilience through activity participation (DeLuca et al 2010, Jessup et al 2010, and Woodier 2011). More broadly, positive emotions have been proposed to be an underlying mechanism for resilient adaptation, associated with resistance to and recovery from stressful life events (Ong et al 2010). Thus some of the successful transitions undertaken by young people may have been aided by positive emotions experienced during the activities which participants described.

When enjoyment is the main reason for pursuing an activity and the level of challenge matches the existing skills, flow or optimal positive experience can occur (Csikszentmihalyi 2002). Such deep and sustained immersion in the activity can contribute to opening up to new opportunities emphasised also in resilience research (Ungar et al 2005), potentially leading to a turning point in a young person’s life. Positive emotions are also related to feeling calm, safe, connected and trust in others (Csikszentmihalyi 2002), which may have further contributed to successful resilience outcomes of the kind reported by our participants.

Because children and youth naturally enjoy play (S Bazyk and J Bazyk 2009), experience of flow may be a significant mechanism in their engagement and resilience. According to flow theory, pursuing the optimal experience is the main motivation, while skills naturally develop as the level of challenge required to enter flow gradually increases (Csikszentmihalyi 2002). Yet, rather than reflecting on the direct impact of the experience of doing, many of the participating professionals emphasised the way in which activities helped people develop transferable social, educational and life skills as was also the case with studies discussed in the literature review (DeLuca et al 2010, Grunstein and Nutbeam 2007, Hart et al 2007, Jessup et al 2010, Peck et al 2008, Scholl et al 2004, Woodier 2011).

Given that enjoyment may be central in promoting positive experience and success, a good knowledge of how to nourish such experience would seem to be important for those using activities to support young people. There was some suggestion this was more challenging when young people presented with disabilities that professionals were less familiar with. Despite Csikszentmihalyi’s (2002) indication that matching challenges and skills is a vital component of achieving flow (2002), and suggestions that it may also promote resilience (Scholl et al 2004, Ungar et al 2005, DeLuca et al 2010), there was limited discussion by the professionals interviewed in this study of the importance of adapting activities, and increasing the level of challenge. That is not to say that participants did not use strategies of adaptation and grading that are familiar to occupational therapists (Creek 2010) – rather, it may be that the participants’ professional backgrounds provided them with lenses which drew attention to other areas and a language which is better able to express them rather than occupational factors. Similarly, whilst there was little evidence of using goal setting strategies (Dawes and Larson 2010), professionals showed their expertise in rule-setting, fostering collaboration and debriefing – helping youth to consider more constructive stories about themselves and others around them. This was also recognised to be important by DeLuca et al (2010), Jessup et al (2010) and Woodier (2011).

While flow involves a deep level of enjoyment with the awareness of time and space drifting into the background, mindfulness-based activities, also highlighted in the findings, entail conscious awareness of whatever arises in one’s physical, emotional and social being, including unpleasant experience (Reid 2011). In some cases the state of mindfulness and flow may merge and more research is required to examine this. Nevertheless, the findings support Rempel’s (2012) literature review which identified an association between mindfulness and pursing positive experience, reducing problem behaviours and promoting desired outcomes. Similarly, Schonert-Reichl and Lawlor’s (2010) high quality quasi-experimental study found mindfulness can significantly increase positive emotions, social and emotional competence, particularly optimism, self-awareness, attention and concentration, in turn improving classroom learning and resilience. While their finding is consistent with the current study, Sara’s relapse suggests that following up mindfulness interventions is important.

Retired practitioners in the current study suggested that addressing a young person’s capacity to cope with adversity on an individual basis alone may not be sufficient to sustain resilience – a point advanced by resilience researchers such as (Hart et al 2007) and Ungar (2009). Many young people had a history consistent with Wilcock and Hocking’s (2014) definition of occupational deprivation involving limited opportunities to engage in meaningful occupations due to the lack of resources, poverty and fragmented families. In this context maladaptive coping strategies became attractive alternatives to meet their physical and psycho-social needs (Caldwell and Smith 2013, S Bazyk and J Bazyk 2009). The UK government is targeting child poverty (HM Government 2014), however, the proposed strategy has been critiqued as insufficient in the context of widening inequalities and more comprehensive resources, child protection and wellbeing approaches are required (Kids Company 2014).


The interpretation of data was influenced by the researcher’s unique life experience and could be interpreted differently by other researchers. Multiple factors contribute to resilience, and this study highlighted the contribution of activity participation and only from the professionals’ perspectives. Young people’s experiences might have been different and future studies could gather data from both parties. Memory bias is also possible and further research could include interviewing current professionals. Recruiting occupational therapists could provide a comparative analysis of how that profession’s use of activities across services has changed over time. Definite conclusions are difficult to draw from the study due to the heterogeneity of the professionals’ and youth backgrounds, activities, services and points in history.

Implications for practice

Structured enjoyable activities can be significant in promoting resilience. The practitioners in the current study made valuable contributions that have clear relevance to occupational therapists and other people working with children and young people in adverse circumstances. This includes nurturing the experience of fun, mindfulness applications, family-centred practice, debriefing strategies, promoting collaboration, creative interventions, and considering longer-term impact of participation in activities on young people’s resilience. Analysis also suggest there are opportunities in this area of practice for occupational therapists to offer their knowledge of a broad range of disabilities and associated functional impact, and their expertise in individualised goal setting and activity grading.


Analysis suggests that key mechanisms through which participation in structured activities promoted resilience for the young people were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; alongside this, the presence of opportunities for constructive relationships and therapeutic support were important contextual factors. Participants noticed a number of changes over time to policy and service provision. Increased integration of services were judged to have improved efforts at resilience building, whilst concerns were expressed with regard to funding constraints and that administrative monitoring of professionals’ work provided less time for active engagement with youth. Analysis also identified opportunities for occupational therapists and occupational perspectives to make a greater contribution to supporting young people in adversity.

Key findings:

  • Enjoyable structured activities can promote youths’ resilience
  • Key mechanisms were: promoting positive emotional experiences and expression; developing routines, responsibility and roles; enabling constructive relationships and providing therapeutic support

What the study has added:

Increased understanding of how participation in structured activities can build young people’s resilience. More broadly the study has helped establish the relevance of occupational perspectives to resilience research and practice.


The authors thank: firstly, the participants for sharing their rich experiences; and secondly, Professor Angie Hart and other members of the Boing-Boing Resilience Research and Practice network and collaborators in the Connected Communities Imagine project for advice and inspiration.

Kristina Usaite, Occupational Therapist, Sussex Partnership NHS Foundation Trust; University of Brighton and Dr Josh Cameron, Principal Lecturer, School of Health Sciences, University of Brighton.

Reference list

Archer MS (1995) Realist Social Theory: the Morphogenetic Approach. Cambridge: Cambridge University Press.

Bazyk S and Bazyk J (2009) Meaning of occupation-based groups for low-income urban youths attending after-school care. American Journal of Occupational Therapy 63(1): 69-80.

boingboing (2013) Resilience forum, University of Brighton. Available at: (accessed 15 October 2013).

Caldwell LL and Smith EA (2013) Leisure as a context for youth development and delinquency prevention. In: France A and Homel R (eds) Pathways and Crime Prevention: Theory, Policy and Practice. New York: Routledge, pp. 271-297.

Clandinin DJ and Connelly FM (2000) Narrative Enquiry: Experience and Story in Qualitative Research. San Francisco: Jossey-Bass.

Creek J (2010) The Core Concepts of Occupational Therapy: a Dynamic Framework for Practice. London: Jessica Kingsley Publishers.

Csikszentmihalyi M (2002) Flow: the Classic Work on How to Achieve Happiness. New York: Random House.

Danermark B, Ekstrom M, Jakobsen L and Karlsson JC (2002) Explaining Society: Critical Realism in the Social Sciences. Abingdon: Routledge.

Dawes NP, Larson R (2011) How youth get engaged: grounded-theory research on motivational development in organized youth programs. Developmental Psychology 47(1): 259-269.

DeLuca C, Hutchinson NL, DeLugt JS, Beyer W, Thornton A, Versnel J, Chin P and Munby H (2010) Learning in the workplace: fostering resilience in disengaged youth. Work: A Journal of Prevention, Assessment and Rehabilitation 36(3): 305-319.

Grunstein R and Nutbeam D (2007) The impact of participation in the Rock Eisteddfod Challenge on adolescent resiliency and health behaviours. Health Education 107(3): 261-275.

Hart A, Blincow D, and Thomas H (2007) Resilient Therapy: Working with Children and Families. Hove: Routledge.

Hart A and Heaver B (2013) Evaluating resilience-based programs for schools using a systematic consultative review. Journal of Child and Youth Development 1(1): 27-53.

HM Government (2014) Child poverty strategy 2014-17. London: TSO.

Imagine (2015) Imagine: Work package 2: the historical context. Available at: (accessed 23 February 2015).

Jessup GM, Cornell E, and Bundy AC (2010) The treasure in leisure activities: fostering resilience in young people who are blind. Journal of Visual Impairment and Blindness 104(7): 419-430.

Kids Company (2014) How did we get here? A review and analysis of children’s services policy and practice from 1945 to 2014. London: Kids Company. Available at: (accessed on 31 July 2014).

Kirk J and Wall C (2010) Resilience and loss in work identities: a narrative analysis of some retired teachers’ work‐life histories. British for research, practice, and translational synergy. Development and Psychopathology 23(2): 493-506.

Masten AS, Cicchetti D (2010) Developmental cascades. Development and Psychopathology 22(03): 491-495.

Ong AD, Bergeman CS and Chow SM (2010) Positive emotions as a basic building block of resilience in adulthood. In: Reich JW, Zautra AJ and Hall JS (eds) Handbook of Adult Resilience. New York: The Guildford Press.

Polkinghorne DE (2010) The practice of narrative. Narrative Inquiry 20(2): 392-396.

Reid D (2011) Mindfulness and flow in occupational engagement: presence in doing. Canadian Journal of Occupational Therapy 78(1): 50-56.

Rempel K (2012) Mindfulness for children and youth: a review of the literature with an argument for school-based implementation. Canadian Journal of Counselling and Psychotherapy 46(3): 201-220.

Rutter M (2012) Resilience as a dynamic concept. Development and Psychopathology 24(02): 335-344.

Scholl L and Mooney M (2004) Youth with disabilities in work-based learning programs: factors that influence success. The Journal for Vocational Special Needs Education, 26(2): 4-16.

Schonert-Reichl KA and Lawlor MS (2010) The effects of a mindfulness-based education program on pre-and early adolescents’ well-being and social and emotional competence. Mindfulness 1(3): 137-151.

Silverman D (2010) Doing Qualitative Research: a Practical Handbook. London: Sage.

Teram E and Ungar M (2009) Not just the master discourse: a case for holistic case studies of youth resilience. In: Ungar M and Liebenberg L (eds) Researching Resilience. Toronto: University of Toronto Press, pp.103-128.

Ungar M (2009) A sample research proposal for a mixed-methods investigation of resilience: the pathways to resilience project. In: Ungar M and Liebenberg L (eds) Researching Resilience. Toronto: University of Toronto Press, pp.271-296.

Ungar M, Dumond C, and Mcdonald W (2005) Risk, resilience and outdoor programmes for at-risk children. Journal of Social Work, 5(3): pp.319-338.

Wilcock AA, Hocking C (2014) An Occupational Perspective of Health. 3rd ed. Thorofare: Slack Incorporated.

Wiseman LM, Whiteford G (2007) Life history as a tool for understanding occupation, identity and context. Journal of Occupational Science 14(2): 108-114.

Woodier D (2011) Building resilience in looked after young people: a moral values approach. British Journal of Guidance & Counselling, 39(3): pp.259-282.

World health organisation (2012) Health behaviour in school-aged children international report from the 2009/2010 survey. Copenhagen: WHO. Available at: (accessed 21 December 2014)


An investigation into the use of humour among Paramedics as a factor in coping with stress and an element affecting resilience against burnout. A Literature Review


The word ‘Humour’ originates from the Latin for ‘fluid’ (Buxman 2008). Historically it was believed that the body contained four ‘humours’ (Blood, Phlegm, Yellow Bile and Black Bile), which governed a person’s health (Scott 2007). Today, though humour is considered ‘the quality of being funny’ (Collins English Dictionary 2011) there is no universally accepted definition (Buxman 2008; Moran 1990). Humour has a multidimensional value in healthcare (Beck 1997, 346); to help calm patients (Beck 1997), as a stress coping strategy (Mildenhall 2012), educational tool (Baid and Lambert 2010), and for group cohesion (Watson 2011).
The question of what affect different types of humour and different humour styles might have upon stress coping strategies is a significant one (Dyck and Holtzman 2013); especially for healthcare (Moran and Massam 1997). The aim of this literature review is therefore to analyse what is currently known in this area, highlighting aspects relevant to paramedic practice and possibilities for future research.


In order to achieve the aim of the study a systemic literature review was conducted. Initial searches of the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, NHS Evidence, PubMed, ScienceDirect and Google Scholar databases using the keywords: burnout’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘resilience’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘, ‘humour’/ ‘humor’ AND ‘paramedic’ OR ’emergency medical personnel’ OR ‘EMT’ OR ‘prehospital’ OR ‘pre-hospital‘. The Boolean operators AND and OR were incorporated to combine search terms and focus results in the relevant area under consideration (Hart 2005). American/English spelling adaptations were included to locate all relevant literature (Moule and Goodman 2009). Searches yielded a significant number of studies but not all were available in full text. Those giving only abstracts were examined to see if they had noteworthy relevance; where found to, alternative avenues were investigated to acquire the full text. Some were obtained through online libraries via Google Scholar. Others, unavailable without payment, were excluded from the review. In order to conclude to the most suitable and narrow results the following inclusion and exclusion criteria were used:

  • Primary research: written by the person who developed the theory or conducted the original research (Polit and Beck 2006)
  • Published in English
  • Peer reviewed: research examined for bias or inappropriate subjectivity by the researcher’s peers or colleagues (Holloway and Wheeler 2010)
  • Free to Access

Due to the relative infancy of research into burnout (Felton 1998) and the older study of humour use (McCreadie and Wiggins 2008) no year of publication boundaries were set; resulting in the discovery of research which significantly informed this review. Additionally, worldwide parameters were allowed to investigate whether use of humour might uncover research with cultural factors relevant to the diversity of healthcare workers in Britain. Though people from ethnic minorities made up only 2% of ambulance staff in 2005 (National Guidance Research Forum 2005) it could be argued that paramedics engage with many healthcare workers in and out of the NHS as part of their work, making this consideration initially relevant. However, as only a limited number of studies, of minimal relevance were uncovered this review concentrates on first world research.

Secondary sources ‘can provide rich data’ (Munhall 2007, 382), however, they are only used where primary research was unobtainable and then limited to discussion areas or additional reference support. This is because secondary sources are one author’s commentary upon another author’s primary research, which can raise concerns over interpretation or bias (Macnee and McCabe 2008).

The Journal of Paramedic Practice was manually searched (due to online inaccessibility) with one article uncovered, aiding discussion elements.
Data saturation ‘indicates that everything of importance to the agenda of a research project will emerge in the data and concepts obtained’ (Holloway and Wheeler 2010, 146). This point was considered reached after repeated searches revealed the same articles closest to the research question.

Qualitative research studies the meaning people give to phenomena (Parahoo 2006), whereas quantitative research investigates ‘phenomena lending itself to precise measurement’ (Polit and Beck 2010, 565). The framework of Lobiondo-Wood and Haber (2002) (appendix 2) for critiquing qualitative and quantitative research was used to critique the three main studies considered central to the research question. Additional research was identified using a snowballing technique – where references in one study lead to locating works by other authors (Polit and Beck 2010).


Review of the research uncovered three main themes:

  1. Burnout: a condition experienced by paramedics
  2. Humour: a factor in stress relief and resilience
  3. Humour use by paramedics

Burnout: a condition experienced by paramedics

Originally used to describe the cessation of a jet engine, Felton (1998) additionally notes that in the 1970’s burnout was first applied to humans by psychologist Herbert Freudenberger. Freudenberger studied how healthcare personnel he worked with changed from being passionate about their job to becoming distant and apathetic; describing themselves as ‘burnt out’ (Ruysschaert 2009). Building on Freudenberger’s work, Maslach and Jackson (1981) published their research into the measurement of burnout, which became seminal for subsequent studies.
Burnout produces a combination of emotional exhaustion, de-personalisation, and reduced personal accomplishment (Maslach and Jackson 1981) being most frequently found among ‘human services professionals, particularly in healthcare’ (Felton 1998, 237). Chase (2014, 1) proposes that ‘no one burns out who wasn’t on fire to begin with’, suggesting burnout is peculiar to people with high expectations of themselves. Maslach and Leiter (2005) agree, proposing that idealists, perfectionists and those with a strong sense of purpose are most at risk. When ideals of relieving suffering, and expressing compassion, are thwarted by time or circumstance a sense of failure and inadequacy can lead to chronic stress and burnout (Chase 2014). The effect of burnout may include physical and emotional exhaustion, increased levels of anger, headache, insomnia, chronic hypertension, gastrointestinal complaints, immune dysfunction, infertility, sleep disorders (Felton 1998; Sophianopoulos, Williams & Archer 2012) as well as higher rates of alcoholism, drug abuse, increased smoking and caffeine intake and coronary heart disease (Frank and Ovens 2002).

Nirel et al (2008) identifies lack of administrative support, long hours, poor work / life balance, and poor salaries as causes of burnout in paramedics particularly. Sophianopoulos, Williams & Archer (2012) add shift work to this list. The impact of burnout upon paramedic’s families is also noted by Regehr (2005), significantly affecting the quality of interpersonal relationships. Increased levels of depression were noted by Griner (2013), with increased percentages of suicidal ideation acknowledged by Sterud et al (2008).

Much literature on burnout makes mention of Maslach and Jackson (1981), Griner (2013) noting burnout is usually measured in healthcare workers using Maslach’s Burnout Inventory (MBI) developed from this research. MBI is a self administered questionnaire which notes a range of responses to an individual’s feelings about their work (Kashka, Korczak & Broich 2011).

‘The Measurement of Experienced Burnout’ by Maslach and Jackson (1981) was first presented in the peer reviewed Journal of Occupational Behaviour, published by Wiley since 1980 ( The authors acknowledge use of qualitative data drawn from other researchers, citing: Freudenberger (1974; 1975), Ryan (1971) and Wills (1978), as well as previous personal research (Maslach 1976), and collaborative work with Pines (1977), however no reference is made to any literature review being conducted. This is possibly due to the infancy of research into burnout at the time (Felton 1998) or that some researchers prefer a brief overview rather than comprehensive literature review to set their study in context (Polit and Beck 2004). Additionally, ethical considerations are not mentioned, though it is unlikely researchers would neglect the basic principles of safeguarding participant’s rights and ensuring their safety (Parahoo 2006). Furthermore, footnotes acknowledge the study was supported by a Bio-Medical Sciences grant, which is awarded only after submission of an application showing all research considerations have been covered (Polit and Beck 2004). Two sample groups were drawn from a range of human services occupations across America including: Physicians, Police, Psychiatrists, Nurses, Social Workers and Counselors. Qualitative data was gathered through semi-structured interviews – presenting a set of questions allowing for individual responses but leading to similar data from participants (Holloway and Wheeler 2010), and quantitative data through questionnaires – a means of collecting specific, measurable data (Holloway and Wheeler 2010). How participants were recruited is not recorded. An initial 47 item questionnaire concerning ‘feelings and attitudes about work’ was compiled with each statement rated on two dimensions: Frequency and Intensity. An answer range of 1-7 gave options between ‘never’, to ‘every day’. This questionnaire was initially administered to 605 people – being a large enough group to be representative of the whole 1025 member sample (Polit and Beck 2010).

Four factors were discovered from the data and titled: ‘Emotional Exhaustion, ‘De-personalisation‘, ‘Personal Accomplishment’ and ‘Involvement’. The fourth factor, though appearing consistently in the data was rejected as a subscale due to its eigenvalue ‘being inconsistent with reliability’ (Maslach and Jackson 1981, 104).

Since publication MBI has been tested by numerous researchers; Schaufeli and Enzmann (1998), cited by Glasberg, Eriksson & Norberg (2007) suggest 90% of empirical studies into burnout now use MBI, giving credence to its dependability. MBI has also been used in organisational settings other than healthcare, including a telecommunications company, pension company and insurance company (Gonzalez-Roma et al 2006) increasing confidence in the transferability of MJ findings.

MJ found that results due to age varied, with younger people scoring higher risk of burnout than older – this is potentially significant when compared to McAlister and McKinnon (2009) who found similar factors in their study of student and qualified paramedics in Australia. The suggestion of Gayton and Lovell (2012) that healthcare workers with longer service owe their resilience to an element of natural selection is also interesting to note in light of this. Married workers were found to have lower risk of burnout than single or divorced workers – possibly equated to the beneficial factor of greater social support noted by Gustafsson et al (2010) and Dyrbye et al (2010).

MJ conclude with the desire that MBI may lead to greater understanding of burnout, ‘influencing future job training, recruitment and design to alleviate the problem’ (Maslach and Jackson 1981, 112); its widespread adoption by researchers (as mentioned above) suggests some accomplishment of this.

Stress is a significant issue within the NHS with an estimated 30% of all staff sickness absence related to it (NHS Employers 2012). Paramedics are particularly susceptible to levels of stress that can lead to burnout (Regehr and Millar 2007) and like other human service workers they use diverse strategies to cope with it (Hawkins 2008). The following chapter examines one strategy, humour use, which has a particular relationship to the emergency services (Charman 2013).

Humour: a factor in stress relief and resilience

Defined as ‘the ability to rebound from adversity and overcome difficult circumstances in life’ (McAlister and McKinnon 2009, 372), resilience is identified by researchers as key in the avoidance of burnout (Gayton and Lovell 2012).
Resilience consists of different factors including level of social support and personality (Grafton, Gillespie & Henderson 2010). However, of all factors highlighted in the development of resilience, the use of ‘humour’ stands out as a common theme (Essex and Benz-Scott 2008; Felton 1998; Grafton, Gillespie & Henderson 2010; Griner 2013; Ruysschaert 2009; Strumpfer 2003).

A ‘complex phenomenon, incorporating cognitive, emotional, behavioural, physiological and social aspects’ (McCreadie and Wiggins 2009, 1079), studies have lead to three basic theories of humour types:

The Incongruity Theory: developed by Kant (1724-1804) notes the ‘punch line’ is different from that expected, – humour being derived from this mismatch (McCreadie and Wiggins 2008).

The Superiority Theory: developed by Plato (427-347) and Hobbes (1588-1679) suggests we laugh at the failings of others to feel better about ourselves (Feagai 2011).

The Relief Theory: developed by Freud (1856-1939) suggesting humour releases suppressed emotions (Hawkins 2008).

Though examples of all three can be found in resilience strategies, Freud’s theory is perhaps more significant as it aims to relieve anxiety and transform negative feelings (Buxman 2008). In ‘The Joke and its Relation to the Unconscious’ (Freud 2002), Freud suggests humour provides an acceptable form for raising taboo subjects, additionally offering a means for ridiculing and dis-empowering people’s fears. The idea of weakening a threat or fear through ridicule is one also attested to by Downe (1999) and Obrdlik (1942); McGhee (2013) suggesting this is due to the increased sense of control humour brings to stressful situations. Henman (2001) corroborates, having found humour fundamental to resilience amongst American prisoners of war in Vietnam and survivors of concentration camps. The significance of this is not lost when considering the stresses of emergency care.

Kuiper (2012), and Dean and Major (2008) found humour helped medical personnel distance themselves from stressful situations; Chinery (2007, 1) calling humour a ‘buffer’ against stress.

Several researchers note claims over the positive health effects of humour (McCreadie and Wiggins 2008) including: reduction of anxiety, increased pain tolerance, improved respiration (Buxman 2008), lowering of blood pressure (McCreadie and Wiggins 2008) and release of endorphins (Fabry 2011; Feagai 2011). However, the most cited case is that of Norman Cousins whose recovery from Ankylosing Spondylitis is often claimed due to humour use (Moran and Massam 1997).

In Anatomy of an Illness, Cousins states: ‘ten minutes of belly laughter had an anaesthetic effect giving me two hours of pain-free sleep.’ (Cousins 1979, 15) Rowe and Regehr (2010), and Mahony (2000) are not alone in challenging Cousins’ claims after subsequent research left them unproven.

On claims of stress reduction Moran and Massam (1997) cite Martin and Lefcourt (1983) who suggest sense of humour does not lead to decreased stress but rather that humorous people generate more humour to cope with stress. To the claim that humour increases pain tolerance, Weisenburg, Tepper & Swartzwald (1995) discovered humour had only a distracting effect, with similar results produced in sample participants watching horror films as humorous films (Weisenburg, Tepper & Swartzwald 1995, 210).

Mahony (2000) found no empirical support confirming laughter triggers endorphin release and suggests watching fish is as effective as humour at lowering blood pressure (Mahony 2000, 2). Mahony’s conclusion: ‘Humour trait is more beneficial than humour state’ (Mahony 2000, 2).

Research into humour use identifies four distinct humour styles revealing how people communicate with others, cope with stress, and build resilience (Dyck and Holtzman 2013): Affiliative Style: strengthening interpersonal relationships whilst maintaining positive self-esteem (Olson et al 2005), Self-Enhancing Style: Having a humorous outlook on life, boosting self-esteem and buffering against stress (Olson et al 2005), Aggressive Style: ‘put down’ humour / sarcasm and ridicule – often having a negative effect on interpersonal relationships (Kuiper 2012), Self-Defeating Style: being excessively critical or ridiculing of one’s self in an attempt to enhance relationships (Kuiper 2012).

For building resilience and coping with stress, affiliative and self enhancing humour are considered positive, whereas aggressive and self-defeating styles are considered negative (Hawkins 2008).

As well as acknowledging humour styles have positive and negative effects, Dyck and Holtzman (DH) questioned whether social support and gender might be factors which further influence the effect of these styles on well-being. Their quantitative method gathered a sample of 826 students, 65.3% Female, 74.3% Caucasian; with 88.7% between age 18-22. Participants were recruited through the psychology research pool at two Canadian universities. A ‘convenience sample’ – those most easily available (Polit and Beck 2010; Holloway and Wheeler 2010), this sample could be accused of bias (Polit and Beck 2004) as they were drawn from students interested in psychology research and therefore not truly representative of all university students. Data was gathered using online questionnaires, results being subjected to bivariate analysis – a means of quantitatively analysing two variables to determine the relationship between them (Babbie 2009). Analysis revealed:

Affiliative Humour was:

  • The highest average score
  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support

Self-Enhancing Humour was:

  • associated with lower levels of depressive symptoms
  • associated with higher levels of life satisfaction
  • associated with higher levels of perceived social support.

Aggressive Humour was:

  • significantly higher in males than females
  • not significantly associated with depressive symptoms, life satisfaction or levels of perceived social support.

Self-Defeating Humour was:

  • The lowest average score
  • associated with greater depressive symptoms
  • associated with lower life satisfaction
  • associated with lower levels of perceived social support.

DH suggest that affiliative and self-enhancing humour styles could be interpreted as more socially attractive and therefore act to increase a person’s social support, whereas aggressive and self-defeating styles could produce the opposite. However, they note a potential alternative explanation might be that social support has a controlling influence on humour styles and their affect on well-being. High social support might enhance the use of positive styles, and diminish the effect of negative styles; whilst lower social support may have the opposite effect.

The application of this study to the paramedic setting is interesting in that it suggests social support; gender and humour styles all have an effect on well-being and potential resilience levels. The Ambulance Service has been a traditionally ‘male’ dominated environment (Sterud et al 2008, Bennett et al 2004) with potential for steering humour towards aggressive styles, (possibly less beneficial for female staff). Levels of social support within the Ambulance Service have also been identified as significant in the area of burnout and resilience (Van de Ploeg and Kleber 2003). In the following chapter the issue of humour use by ambulance staff will be examined to consider its effect upon resilience to burnout.

Humour use by Paramedics

Rebuffing the idea that humour in healthcare is unprofessional, Dean and Major (2008) champion its value in aiding communication, managing emotion, team building and burnout avoidance. Furthermore, within emergency healthcare research a common theme is the use of ‘gallows humour’ (GH) for stress relief (Alexander and Klein 2001; Bennett 2003; Rosenberg 1991).
GH is often used at times of tragedy or death (Bennett 2003, 1259). Freud (2002) notes its use by individuals, but Obrdlik (1942), in a study of the Nazi invasion of Czechoslovakia, was one of the first to document its use by whole societies. Its use by groups in stressful work environments has since been acknowledged (Moran and Massam 1997).

Amongst many paramedics, GH is considered ‘the biggest coping mechanism we have’ (Villeneuve 2005, 8). Diminishing negative feelings by re-framing a horrific situation GH offers a defense in overpowering situations (Van-Wormer and Boes 1997); whilst ‘maintaining sanity under insane circumstances’ (Kuhlman 1988; cited in: Rowe and Regehr 2010, 449). Several researchers noted how paramedics use humour to develop their social support (Mildenhall 2012) and build group cohesion (Rowe and Regehr 2010).

A seminal, qualitative study into humour use by paramedics is Rosenberg (1991) ‘A qualitative investigation of the use of humor by emergency personnel as a strategy for coping with stress’, which compares humour use by experienced and student paramedics, noting the development and adaptation of humour through exposure to clinical experience and exploring how changes in humour use may be ‘an adaptive method for coping with stress’ (Rosenberg 1991, 197).

Longitudinal research – ‘examining changes in a group over time’ (Burns and Grove 2001, 251), was incorporated in studies of 10 (ultimately 9) student paramedics from a convenience sample of 37. Known as the ‘pre/post trained group’, they were firstly interviewed before training, and then interviewed again after training.

A second group of 10 ‘experienced’ paramedics with 1-7 years experience were additionally recruited and interviewed once only. Their results, compared with the first group, provided cross sectional data for the study. Cross sectional research gives data from ‘more than one group of subjects at various stages of development, simultaneously’ (Burns and Grove 2001, 252).

Though participant numbers were small, data saturation – where no new data is uncovered (Polit and Beck 2010) was highly probable as the groups were representative of the ‘student’ and ‘experienced’ populations. Data was gathered using a structured interview – ‘the same questions, in same order, with same response options’, (Polit and Beck 2004, 349), but with open ended questions – ‘giving freedom to respond in narrative fashion’ (Polit and Beck 2004, 349). Inductive analysis – taking specific facts to form general theory (Macnee and McCabe 2008), ‘without the restraints imposed by structured methodologies’ (Thomas 2003, 2), was employed to make maximum use of the data; enabling recurrent themes to be categorized and counted.

Charman (2013); Mildenhall (2012); and Rowe and Regehr (2010) acknowledge the same with regard to humour building group cohesion, teamwork and social support.

Context of EMS humour: The ‘experienced’ paramedics stated that ‘they could not share the humour they used at work with family or friends’ (Rosenberg 1991, 199). Bennett (2003) suggests that because humour exists within a certain culture, what is funny to some will not be to others. Those ‘outside’ the group (including family and friends) may be repelled by GH because they ‘cannot fully comprehend the reason for its origin’ (Rowe and Regehr 2010, 456).

Goffman (1959) presents the concept of regions of acceptable behaviour within society. Applied to humour use in healthcare, this proposes that emergency workers have ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments which moderate their behaviour (Williams 2013a). As part of the unwritten rule of GH use, it is only acceptable in the ‘Backstage’ environment of either the crew room or at an incident scene where no non-emergency personnel are present (Williams 2013a; Watson 2011; Mildenhall 2012). GH is never appropriate in the ‘Frontstage’ environment where patient relatives look to paramedics for support (McCarroll et al 1993), and is strongly discouraged in the ‘Offstage’ environment – at home or off duty when paramedics are with relatives and friends, as they are ’outside’ the circle for understanding the nature or origin of the humour (Rosenberg 1991).

Purpose of Humour use: All participants, except three from the pre/post group, stated they used humour as a coping strategy; with the entire experienced group rating it higher in importance as a strategy than any of the pre/post group. The students emphasised the tension relieving aspect of humour use after a bad day which is also acknowledged by Moran (1990), who considers humour more associated with reducing stress after an event rather than during (Moran 1990, 368). In contrast, the experienced group strongly emphasised the cognitive and emotional refocusing power of humour; as noted by Buxman (2008), Freud (2002) and Kotthoff (2006). Rosenberg therefore suggests humour use becomes a deepening or maturing stress defense for paramedics.


This review identified three main themes: ‘Burnout: a condition experienced by paramedics’, ‘Humour: a factor in stress relief and resilience’, and ‘Paramedic use of humour’.
Chronic stress can lead to the three elements of burnout: emotional exhaustion, de-personalisation and diminished sense of accomplishment (Maslach and Jackson 1981). In healthcare this manifests as deterioration in the quality of care, high job turnover, absenteeism and increased health issues for those affected (Maslach and Jackson 1981). As paramedics are among those with the highest risk of burnout (Regehr and Millar 2007), this carries implications both individually and organisationally.

Implications for Paramedics
Maslach and Leiter (2005) and Chase (2014) suggest that a contributing factor in burnout of healthcare workers is the imbalance between the care they desire to give and the care they are able to give. For paramedics, shift work, pressure to meet targets, abuses of the service by some people, and poor work/life balance are elements which affect this (Mildenhall 2012; Nirel et al 2008; Regehr and Millar 2007; Sophianopoulos, Williams & Archer 2012).

Maslach and Leiter (2005) suggest that giving time to stress relieving pursuits such as sporting activities, hobbies and social relationships, enable individuals to defuse the stresses of work which lead to burnout. However, a consequence of shift work is that partners and friends may be at work themselves when paramedics are off duty, with repercussions for social relationships (Harrington 2001). In contrast, Sophianopoulos, Williams & Archer (2012) suggest that families of shift-workers often adapt to their situation, becoming more resilient. Further research in this area might reveal factors contributing to positive social adaptation, of benefit to paramedics.

Access to information on their patient’s outcome is a source of stress for some paramedics (Regehr and Millar 2007); the lack of such information leading to concerns over personal competency (Witmore 2013). Access to patient information is governed by the Data Protection Act (1998) making confidentiality a legal requirement in NHS employment contracts (Department of Health 2003). Legislation allowing paramedics access to information on their patient’s outcome would help reduce incident related stress and encourage reflection (Bishop 2013), potentially improving staff well-being and patient care (Okougha 2013).

Organizational implications
The Health and Safety at Work Act (1974) requires employers to do everything reasonably practicable to protect the health, safety and well-being of their employees, including minimising the risk of stress related illness. As an employer, ambulance Trusts are subject to this legislation. Occupational health departments aim to provide employees access to counseling services, post incident de-briefing opportunities and peer lead support groups (NHS Employers 2012). Additionally, the Boorman Review (Department of Health 2009) recommended the establishment of staff stress management initiatives to further address well-being issues.

The reluctance of paramedics to disclose the full stresses of their work to those in ‘off-stage’ environments means they rely on ‘backstage’ environments (crew-rooms) for relieving the pressure (Williams 2013a). With the introduction of ‘Make Ready’ (SECAmb 2010) where vehicles are re-stocked by contractors rather than crews; and the increased deployment of crews to stand by points, ‘backstage’ time could be significantly reduced. Though possibly beneficial for productivity this removes a potential stress relief outlet for paramedics (Mildenhall 2012). Research into the impact of these initiatives, as well as into ways ambulance services might be proactive in initiating positive approaches to staff at risk of burnout could contribute to a reduction in the strain placed upon services due to absenteeism.

Humour: a factor in stress relief and resilience
The potential of humour as a positive element within healthcare is acknowledged by numerous researchers (Dyck and Holtzman 2013; Rosenberg 1991; Scott 2007; Shepherd and Wild 2014; Watson 2011).

Of the three main Humour Theories (Incongruity; Superiority; Relief), Freud’s ‘Relief Theory’ has the strongest association to humour use by paramedics, suggesting humour can bring a culturally acceptable means of releasing suppressed emotion, dis-empowering a potential threat and re-framing unpleasant experiences into more emotionally and cognitively manageable ones (Buxman 2008; Downe 1999; Henman 2001; McGhee 2013). Mahony (2000, 2) considers ‘humour trait more beneficial than humour state’, a view given weight by studies into humour styles, whereby ‘affiliative’ and ‘self-enhancing’ styles have been found to have a positive influence upon resilience to stress and burnout; whereas ‘aggressive’ and ‘self-defeating’ styles can have a negative effect (Dyck and Holtzman 2013; Stieger et al 2011).

Implications for individuals and organizations
Dyck and Holtzman note how ‘aggressive’ humour styles are more common amongst men; whilst Mahony (2003); and Williams (2012), acknowledge that ambulance services are traditionally male dominated. Citing the Office of National Statistics, Williams (2012) highlights that in 2010 there were ‘approximately 13,000 male paramedics in the UK whilst the number of female paramedics was too small for a reliable estimate’ (Williams 2012, 370). However, figures for registered UK paramedics in November 2013 indicate 7667 female paramedics compared to 12451 male (HCPC 2013). These figures still reveal a predominantly male profession.

Though ‘aggressive humour style’ might not significantly affect male resilience levels, as Dyck and Holtzman (2013) hypothesise, the higher percentage of male paramedics may mean a dominant aggressive humour style exists culturally. As numbers of female paramedics rise the humour culture they encounter may, therefore, have implications for their resilience levels.

Humour use by Paramedics
Whilst humour use for calming patients and relieving stress has been noted, of particular interest is paramedic’s use of ‘gallows humour’ (GH).

Gallows Humour
Helping to re-frame stressful situations, making them more emotionally manageable (Van-Wormer and Bows 1996), GH is most often used in times of tragedy, oppression or death (Bennett 2003; Freud 2002; Moran and Massam 1997; Obrdlik 1942). Its use today being particularly prolific among emergency services personnel (Charman 2013; Mildenhall 2012; Watson 2011).

Rowe and Regehr (2010) point out that GH often appears in general society after a major disaster, suggesting GH offers a means of putting tragedy into perspective. The fact that GH use is prevalent among paramedics (who potentially encounter more traumatic situations than those employed outside emergency, medical or armed forces careers) is therefore understandable (Chase 2014).

Implications for Paramedics
The question of how humour use, particularly GH, relates to professionalism is an obvious one. The Health and Care Professions Council: Standards of conduct, performance and ethics (2012) highlights the expectation that registrants will deal respectfully towards service users, showing integrity, and the highest standards of personal conduct, whilst avoiding any action that would bring their profession into disrepute (HCPC 2012, 3). The potential for inappropriate humour use to breach these standards is strong. However, Rosenberg (1991); Rowe and Regehr (2010); and Williams (2012) indicate that tight boundaries for cultural humour use exist within ambulance services, where GH particularly is considered taboo outside specific environments, or with those outside the accepted group.

The concept of ‘Frontstage’, ‘Backstage’ and ‘Offstage’ environments (defined by whether any non-emergency personnel are present), has been suggested by Goffman (1959); Rosenberg (1991); Watson (2011) and Williams (2012). For paramedics, the ‘backstage’ environment, such as the station crew-room or ambulance vehicle cab, is considered the only one where GH is sanctioned. This self regulated cultural code of conduct would seem to act as a strong deterrent to breaches of professionalism, though cannot guarantee against them. The potential for GH between paramedics to be overheard by non-emergency personnel at the scene of a traumatic event is reasonably high and paramedics should be vigilant in guarding against it.

Implications for the future progression of the Paramedic profession
Literature considered in this review suggests the presence of a humour culture within the Ambulance Service that new recruits are socialised into (Rosenberg 1991). Furthermore, Essex and Benz-Scott (2008); McAlister and McKinnon (2009); Rosenberg (1991) and Villeneuve (2005), observe that recognition of the value of humour use as a coping strategy increases with clinical experience and years of service.

The role of socialisation in conforming new members of a group into cultural norms is a recognised phenomenon (Giddens and Sutton 2013). However, the question of whether socialisation into all aspects of ambulance humour culture is helpful or desirable within the modern Ambulance Service is potentially controversial. The benefits of appropriate humour use for relieving stress are attested to by many and not considered unprofessional (Dean and Major 2008). However, the more negative elements of humour culture such as overly aggressive humour styles and ‘put down’ humour, which Berk (2009) suggests is strongly associated with medical professions, may be unhelpful to some staff as the profession progresses.

Conclusion and Recommendations

This literature review has investigated the use of humour by paramedics as a factor in coping with stress and an element affecting resilience against burnout. Paramedic practice can be acutely stressful at times (Halpern et al 2012) though lower levels of chronic stress also exist within the role (Mildenhall 2012). The combination of this stress can lead to the emotional exhaustion, de-personalisation and loss of personal accomplishment that characterises burnout (Maslach and Jackson 1981).
Humour use has been identified as a factor in resilience and as a coping strategy against burnout among paramedics (Rosenberg 1991), being used as a distancing and re-framing technique in challenging situations and for fostering socialisation and group cohesion (Charman 2013). Its role in the development of student paramedics is also significant (Dean and Major 2008; Rosenberg 1991).

  • Recommendations for future research and practice as a result of this review include:
  • Investigating the effect of increases in female clinical staff numbers on the humour culture and staff resilience levels within the Ambulance Service.
  • Examining the impact of initiatives such as ‘Make Ready’ and reduced time at base stations upon paramedic’s resilience to burnout.
  • Exploring the socialisation process of student and newly registered paramedics into the Ambulance Service; the role humour plays in this and its effect on the development of group culture.

Chris Storey Paramedic Practice BSc (Hons) student


Alexander, D.A. and S. Klein. 2001. Ambulance personnel and critical incidents: impact of accident and emergency work on mental health and emotional well-being. British Journal of Psychiatry 178(1)76-81.

Babbie, E.R. 2009. The practice of social research. 12th ed. Belmont: Wadsworth Publishing.

Baid, H. and N. Lambert. 2010. Enjoyable learning: the role of humour, games and fun activities in nursing and midwifery education. Nurse Education Today 30(6) 548-552.

Beck, C. T. 1997. Humor in nursing practice: A phenomenological study. International Journal of Nursing Studies 34(5) 346-352.

Bennett, H.J. 2003. Humour in medicine. Southern Medical Journal 96(12) 1257-1261.

Bennett, P., Y. Williams., N. Page., K. Hood. and M. Woollard. 2004. Levels of mental health problems among UK emergency ambulance workers. Emergency Medical Journal 21(2) 235-236.

Bishop, A. 2013. Question regarding patient information. [email] Personal email to C. Storey. [11 November 2013].

Blau, G. and S. Chapman. 2011. Retrospectively exploring the importance of items in the decision to leave the emergency medical services (EMS) profession and their relationships to life satisfaction after leaving EMS and likelihood of returning to EMS. Journal of Allied Health 40(2) 29-32.

Burns, N. and S.K. Grove. 2001. The practice of nursing research: conduct, critique and utilization. 4th ed. Philadelphia: W.B. Saunders.

Buxman, K. 2008. Humor in the OR: a stitch in time? Association of Peri-Operative Registered Nurses Journal 88(1) 67-77.

Charman, S. 2013. Have you heard the one about the emergency services’ joke-book? Ambulance Today 2013 (Autumn) 41-43.

Chase, R. 2014. Stress and burnout. [Online]. Available at: (Accessed 29/1/14).

Chinery, W. 2007. Alleviating stress with humour: a literature review. [Online] Available at: (Accessed 1/3/14).

Collins English Dictionary. 2011. 11th ed. Glasgow: Harper-Collins.

Cousins, N. 1979. Anatomy of an illness: as perceived by the patient: reflections on healing and regeneration. PDF [Online]. Available at : (Accessed 1/3/14).

Data Protection Act. 1998. London: Stationary Office.

Dean, R.A.K. and J.E. Major. 2008. From critical care to comfort care: the sustaining value of humour. Journal of Clinical Nursing 17(8) 1088-1095.

Department of Health. 2003. Confidentiality – NHS code of practice. Norwich: Stationery Office.

Department of Health. 2009. NHS health and well-being: final report. [Boorman Review]. Norwich: Stationery Office.

Downe, P.J. 1999. Laughing when it hurts: humour and violence in the lives of Costa Rican prostitutes. Women’s Studies International Forum 22(1) 63-78.

Dyck, K.T.H. and S. Holtzman. 2013. Understanding humor styles and well-being: the importance of social relationships and gender. Personality and Individual Differences 2013 55(1) 53-58.

Dyrbye, L.N., D.V. Power., F.S. Massie., A. Eacker., W. Harper., M.R. Thomas., D.W. Szydlo., J.A. Sloan. and T.D. Shanafelt. 2010. Factors associated with resilience to and recovery from burnout: a prospective, multi-institutional study of US medical students. Medical Education 44(10) 1016-1026.

Essex, B. and L. Benz-Scott. 2008. Chronic stress and associated coping strategies among volunteer EMS personnel. Prehospital Emergency Care 12(1) 69-75.

Fabry, D. 2011. Hello to humour and goodbye to burnout. Audiology Today March/April 2011 36-37.

Feagai, H.E. 2011. Let humour lead your nursing practice. Nurse Leader August 2011 44-46.

Felton, J.S. 1998. Burnout as a clinical entity – its importance in healthcare workers. Occupational Medicine 48(4) 237-250.

Frank, J.R. and H. Ovens. 2002. Shift work and emergency medical practice. Canadian Journal of Emergency Medical Care 4(6) 421-428.

Freud, S. 2002. The joke and its relation to the unconscious: translated by J. Crick. London: Penguin.

Gayton, S.D. and G.P. Lovell. 2012. Resilience in ambulance service paramedics and its relationship with well-being and general health. Traumatology 18(1) 58-64.

Giddens, A. and P.W. Sutton. 2013. Sociology. 7th ed. Cambridge: Polity Press.

Glasberg, A.L., S. Eriksson. and A. Norberg. 2007. Burnout and ‘stress of conscience’ among healthcare personnel. Journal of Advanced Nursing 54(4) 392-403.

Goffman, E. 1959. The presentation of self in everyday life. New York: Doubleday.

Gonzalez-Roma, V., W. B. Schaufeli., A.B. Bakker. and S. Lloret. 2006. Burnout and work engagement: independent factors or opposite poles? Journal of Vocational Behaviour 68(1) 165-174.

Grafton, E., B. Gillespie. and S. Henderson. 2010. Resilience: the power within. Oncology Nursing Forum 37(6) 698-705.

Griner, P.F. 2013. Burnout in healthcare providers. Journal of Integrative Medicine 12(1) 22-24.

Gustafsson, G., S. Eriksson., G. Strandberg. and A. Nordberg. 2010. Burnout and perceptions of conscience among healthcare personnel: a pilot study. Nursing Ethics 17(1) 23-38.

Halpern, J., R.G. Maunder., B. Swartz. and M. Gurevich. 2012. Identifying, describing and expressing emotions after critical incidents in paramedics. Journal of Traumatic Stress 25(1) 111-114.

Harrington, J.M 2001. Health effects of shift work and extended hours of work. Occupational and Environmental Medicine 58(1) 68-72.

Hart, C. 2005. Doing a literature search: a comprehensive guide for the social sciences. London: Sage.

Hawkins, D. A. 2008. Comparing the use of humor to other coping mechanisms in relation to Maslach’s theory of burnout. PhD dissertation. University of Florida. [Online]. Available via online library at: (Accessed: 1/3/14).

Health and Care Professions Council. 2012. Standards of conduct, performance and ethics. London: HCPC.

Health and Care Professions Council. 2013. Registrants gender split: November 2013. Freedom of information log. [Online]. Available via online library at (Accessed 18/6/14).

Health and Safety at Work Act: 1974. Chapter 37. 1974. Norwich: Stationery Office.

Henman, L.D. 2001. Humour as a coping mechanism: lessons from P.O.Ws. Humour 14(1): 83-94. PDF. [Online]. Available via online library at: (Accessed 1/3/14).

Kaschka, W.P., D. Korczak. and K. Broich. 2011. Burnout – a fashionable diagnosis. Deutsches Arzteblatt International 108(46) 781-787.

Kuiper, N.A. 2012. Humor and resiliency: towards a process model of coping and growth. Europe’s Journal of Psychology 8(3) 475-491.

Lobiondo-Wood, G. and J. Haber. 2002. Nursing research: methods, critical appraisal and utilization. St Louis: Mosby.

Macnee, C.L. and S. McCabe. 2008. Understanding nursing research: reading and using research in evidence-based practice. 2nd ed. Philadelphia: Lippincott Williams and Wilkins.

Mahony, D.L. 2000. Is laughter the best medicine or any medicine at all? Psi Chi: The International Honor Society in Psychology 4(3) [Online] Available via online library at: (Accessed 3/3/14).

Mahony, K. 2003. The politics of professionalisation: some implications for the occupation of ambulance paramedics in Australia. The Australian Journal of Paramedicine 1(3) 1-8.

Maslach, C. and M.P. Leiter. 2005. Reversing burnout: How to rekindle your passion for work. Stanford Social Innovation Review. Winter 2005: 43-49. [Online] Available via online library at: (Accessed 29/1/14).

McAlister, M. and J. McKinnon. 2009. The importance of teaching and learning resilience in the health disciplines: a critical review of the literature. Nurse Education Today 29(4) 371-379.

McCarroll, J.E., R.J. Ursano., K.M. Wright. and C.S. Fullerton. 1993. Handling bodies after violent death: strategies for coping. American Journal of Orthopsychiatry 63(2): 209-214. PDF [Online]. Available via online library at: PDF. ADA264372. (Accessed 10/5/14).

McGhee, P. 2013. Humour and Nursing 2: Using humour to cope with the challenges of nursing. Online Continuing Education for Nurses: Corexel. PDF. [Online] Available at: (Accessed 1/3/14).

Moran, C. 1990. Does the use of humor as a coping strategy affect stresses associated with emergency work? International Journal of Mass Emergencies and Disasters 8(3) 361-377.

Moran, C. and M. Massam. 1997. An evaluation of humour in emergency work. The Australian Journal of Disaster and Trauma Studies March 1997. [Online] Available via online library at: (Accessed: 1/3/14)

Moule, P. and M. Goodman. 2009. Nursing research: an introduction. London: Sage.

Munhall, P.L. 2007. Nursing Research: a qualitative perspective. 4th ed. London: Jones and Bartlett.

Murphy, S., R.D. Beaton., K.C. Pike. and K.C. Cain. 1994. Firefighters and paramedics: years of service, job aspirations, and burnout. American Association of Occupational Health Nurses Journal 42(11) 534-540.

N.H.S. Employers. 2012. Welcome to the Team: Ambulance Service Staff. N.H.S. Employers.

Nirel, N., R. Goldwag., Z. Feigenberg., D. Abadi. and P. Halpem. 2008. Prehospital Disaster Medicine 23(6) 537-546.

Obrdlik, A.J. 1942. ‘Gallows humour’. American Sociological Review 47(5): 709-713. [Online] Available via online library at: (1/3/2014).

Okougha, M. 2013. Promoting patient care through staff development. Nursing Standard. 27 (34) 42-46.

Olson, M.L., D.S. Hugelshofer., P. Kwon. and R.C. Reff. 2005. Rumination and dysphoria: the buffering role of adaptive forms of humor. Personality and Individual Differences 39(8) 1419-1428.

Parahoo, K. 2006. Nursing research: principles, process and issues. 2nd ed. Basingstoke: Palgrave Macmillan.

Polit, D.F. and C.T. Beck. 2004. Nursing research: principles and methods. 7th ed. Philadelphia: Lippincott Williams & Wilkins.

Polit, D.F. and C.T. Beck. 2006. Essentials of nursing research: methods, appraisal and utilization. 6th ed. Philadelphia: Lippincott Williams & Wilkins.

Polit, D.F. and C.T. Beck. 2010. Essentials of nursing research: appraising evidence for nursing practice. 7th ed. Philadelphia: Lippincott Williams & Wilkins.

Popa, F., A. Raed., V.L. Purcarea., A. Lala. and G. Bobimac. 2010. Occupational burnout levels in emergency medicine – a nationwide study and analysis. Journal of Medicine and Life 3(3) 207-215.

Regehr, C. 2005. Bringing home the trauma: spouses of paramedics. Journal of Loss and Trauma 10(2) 97-114.

Rosenberg, L. 1991. A qualitative investigation of the use of humor by emergency personnel as a strategy for coping with stress. Journal of Emergency Nursing 17(4) 197-203.

Rowe, A. and C. Regehr. 2010. Whatever gets you through today: an examination of cynical humor among emergency service professionals. Journal of Loss and Trauma 15(5) 449-464.

Ruysschaert, N. 2009. (Self) Hypnosis in the prevention of burnout and compassion fatigue for caregivers: theory and induction. Contemporary Hypnosis 26(3) 159-172.

S.E.C.Amb. 2013. Annual Report and Accounts: 1st April 2012 – 31st March 2013. Banstead: S.E.C.Amb.

Scott, T. 2007. Expressions of humour by emergency personnel involved in sudden deathwork. Mortality 12(4) 350-364.

Shakespeare-Finch, J. and S. Savill. 2013. An investigation into the lived experience of intensive care paramedics. Australia and New Zealand Disaster Emergency Conference: 28th-31st May 2013. [Online]. PDF. Available at: (Accessed: 19/5/14).

Shepherd, L. and J. Wild. 2014. Cognitive appraisals, objectivity and coping in ambulance workers: a pilot study. Emergency Medical Journal 31(1) 41-44.

Sofianopoulos, S., B. Williams. and F. Archer. 2012. Paramedics and the effects of shift work on sleep: a literature review. Emergency Medical Journal 29(2) 152-155.

Stassen, W., B.V. Nugteren. and C. Stein. 2013. Burnout among advanced life support paramedics in Johannesburg, South Africa. Emergency Medical Journal 30(4) 331-333.

Steiger, S., A.K. Formann. and C. Burger. 2011. Humor styles and their relationship to explicit and implicit self-esteem. Personality and Individual Differences 50(5) 747-750.

Sterud, T., E. Hem., B. Lau. and O. Ekeberg. 2008. Suicidal ideation and suicide attempts in a nationwide sample of operational Norwegian ambulance personnel. Journal of Occupational Health 50(5) 406-414.

Strumpfer, D. J.W. 2003. Resilience and burnout: A stitch that could save nine. South African Journal of Psychology 33(2) 69.

Thomas, D.R. 2003. A general inductive approach for qualitative data analysis. PDF. [Online]. Available via online library at: (Accessed 19/4/14).

Van der Ploeg, E. and R.J. Kleber. 2003. Acute and chronic job stressors among ambulance personnel: predictors of health symptoms. Occupational Environmental Medicine 60(supplement) 40-46.

Van Wormer, K. and M. Boes. 1997. Humour in the emergency room: a social work perspective. Health and Social Work 22(2) 87-92.

Weisenberg, M., I. Tepper. and J. Schwarzwald. 1995. Humor as a cognitive technique for increasing pain tolerance. Pain 63(2) 207-212.

Watson, K. 2011. ‘Gallows humor in medicine’. Hastings Center Report 41(5): 37-45. [Online]. Available via online library at: (Accessed: 27/2/14).

Whitmore, D. 2013. A paramedic’s experience of the 7 / 7 bombings. [Lecture] Student Paramedic Conference 17th July 2013. Kingston & St Georges University. London.

Williams, A. 2012. Emotion work in paramedic practice: the implications for nurse educators. Nurse Education Today 12(32) 368-372.

Williams, A. 2013. The strategies used to deal with emotion work in student paramedic practice. Nurse Education in Practice 13(13) 207-212.

Williams, A. 2013. A study of emotion work in student paramedic practice. Nurse Education Today 13(33) 512-517.

Skip to toolbar